Tubal Reversal Surgery and IVF, Utah- Overview of Tubal Reversal Surgery and Comparison to IVF

Tubal reversal surgery (tubal reversal, tubal reanastomosis, and tubal anastomosis) or IVF (in vitro fertilization) are often used to conceive after a previous tubal ligation. (See our comparision of tubal reversal surgery vs. IVF). Tubal ligation is one of the most popular forms of birth control for married couples who believe they have completed their families.

Tubal reversal is sought by approximately 3-5% of patients who chose to undergo permanent sterilization via tubal ligation. However, numerous studies demonstrate that delivered pregnancy success rates per cycle are generally higher using IVF compared to tubal reversal surgery. Tubal reversal surgeries cumulative success rates can approach IVF in the right, carefully screened, patient. Tubal reversal is rarely covered by insurance even if the policy otherwise covers infertility services.

Since 1996, our Utah fertility center, Reproductive Care Center, has offered IVF with high success rates for appropriately selected patients. IVF is an excellent option many couples and has resulted in delivered pregnancy rates well above the national average.

Tubal reversal surgery has recently become more cost competitive. In 2012, an assisted laparoscopic tubal reversal surgical option became available in Utah at Ogden Regional Medical Center.  The advantages and disadvantages of this tubal reversal option are discussed below and on our “Tubal Reversal Utah New Options” Web page.

Tubal reversal surgery is sought more commonly when the tubal ligation was performed prior to the age of 30. About 50% of the time, the reason for the tubal reversal is the desire for more children due to loss of the first spouse, or divorce and subsequent marriage to a new partner. Often the new husband does not have any children or the couple wants to have children together.

Utah is unique in that many of the patients who desire tubal reversal are still married to the same spouse and they already have children. However, circumstances (such as finances or the death of a child) have changed and they want to bring another biological child into their home.

In normal physiology, once the eggs are released (ovulated) from the ovarian follicles they must be picked up by the fimbriated end of the fallopian tubes. The fimbria are fingerlike projections that assist in collection of the egg. As the egg starts to travel down the fallopian tube, fertilization occurs. The embryo remains in the tube for several days prior to reaching the uterus. Any condition, such as endometriosis, that blocks the fallopian tubes inhibits this passage and prevents pregnancy. The location of a blockage can usually be seen with the hysterosalpingogram (HSG) examination.

Tubal Reversal Success Rates

Tubal reversal success rates are partly determined by how/where the tubes were “cut”. Tubal ligation or sterilization is performed using several common methods. These include laparoscopic methods to burn (cautery), clip (Hulka or Filshie clip), cut and remove a section of fallopian tube, band (Falope Ring - small thick rubber band that strangulates the tissue), removal of the distal end of the tube (Krohner fimbriectomy), or complete removal of the fallopian tube (salpingectomy).

In addition, the most common method used during mini-laparotomy immediately after delivery, or at the time of cesarean section, is a partial salpingectomy (removal of a small portion of the tube often with associated burning of the ends of the tube). All of these methods result in blockage of the fallopian tube and do not allow egg transport.

Tubal reversal success depends on numerous factors including the type of surgery that was initially performed to block the tubes (determined from the operative report), the length of remaining tube (estimated based on the operative and/or pathology report), the age and health of the woman, egg quality and quantity (ovarian assessment report test results), adequacy of the uterine cavity (saline sonogram result) and the quality of the husband's sperm.

The success of tubal reversal surgery is also influenced by other factors such as a history of pelvic infection, pelvic adhesions, advanced endometriosis or a prior ectopic pregnancy. All of these conditions can adversely impact tubal reversal success. In optimal conditions, in women under 35, pregnancy rates up to 65-70% within 2 years of the tubal reversal can be achieved. More commonly pregnancy rates approach 50%. In most cases, the per cycle success rates of IVF are much higher than tubal reversal.  See our page on Tubal Reversal Surgery vs. IVF.

Tubal reversal surgery was once primarily a procedure done as an inpatient with a mini-laparotomy that required 3-4 hours of surgery, 2-3 days of hospitalization, and a 4-6 week recovery period prior to returning to work.

Using more modern techniques, we now do tubal reversal as an outpatient procedure using laparoscopy, which decreases the hospital stay and minimizes the recovery period. Tubal reversal surgery using the traditional mini-laparotomy approach often costs more than $10,000 not including any lost time from work. Tubal reversal procedures performed on an outpatient basis significantly reduces cost.

Tubal reversal surgery can be a reasonable option, especially for younger women. Although the per cycle success rates for IVF are much higher, the number of times a young couple can have intercourse to attempt pregnancy is virtually unlimited.

For example, if a couple is having regular intercourse, they are attempting a “natural cycle pregnancy” each month. IVF cycles are relatively expensive and the total number of attempts is often limited by the financial resources of the couple. Some couples may only be able to afford one or two IVF cycles with the pregnancy rate varying according to many patient specific variables.

A couple’s overall cumulative chance for pregnancy may be similar after tubal reversal surgery and 1-2 years of intercourse compared to one IVF cycle. This is highly dependent upon several “couple specific” variables.

If a patient has not conceived by 1 year after tubal reversal surgery, further evaluation with a fertility specialist at Reproductive Care Center is indicated. A hysterosalpingogram (HSG) is usually performed to confirm that at least one tube is open. If the tube(s) are open, further natural cycle attempts can be made or procedures such as ovulation enhancement with IUI (intrauterine insemination) can be considered. If conception has not occurred within 2 years of the tubal reversal, many couples should consider IVF.

Tubal reversal was chosen by fewer patients in the 1990's as IVF pregnancy rates improved. After appropriate counseling regarding the IVF option, many patients chose IVF instead of tubal reversal surgery. The advantages of IVF over traditional mini-laparotomy tubal reversal surgery include:

• Higher pregnancy rate per cycle - >50% for IVF compared to 5-10% per cycle after tubal reversal for ideal candidates.
• Lower risk of ectopic pregnancy in the fallopian tube - 1-2% risk after IVF compared to 8-15% after tubal reversal surgery.
• Quicker time to conception and delivery employing IVF compared to tubal reversal which can be critical for women who are over the age of 35 and may have rapidly declining ovarian reserve.
• Similar or lower cost for IVF compared to tubal reversal surgery.
• Tubal reversal surgery usually requires more time off work for post-operative recovery.

The choice of tubal reversal vs. IVF should only be made after consultation with a subspecialty trained infertility specialist. There are many “couple specific” factors that must be considered and we always recommend the procedure most likely to result in pregnancy success.

The initial consultation is most valuable when the following information is available:

• Call 801-878-8888 or e-mail scheduling@FertilityDr.com to schedule a consultation with an RCC infertility specialist and obtain a password for the RCC patient portal.
• Obtain a copy of the tubal ligation operative report, either from the physician that performed the procedure or from the hospital where it was performed.
• Obtain the following testing: 1)Semen analysis (sperm quality testing) that preferably includes morphology testing using Kruger strict morphology (call RCC to schedule) for the husband. If you have coverage for basic semen analysis (does not include Kruger strict morphology if done in Utah) at an outside center, such as an IHC facility or other hospital, RCC nurses can help arrange for testing. 2)Complete ovarian assessment report testing on day 3 of the menstrual cycle (egg quality testing) is done through ReproSource for the wife.
• Obtain pertinent medical and GYN records.
• Complete the online RCC patient questionnaire information for both the husband and the wife.

Once the surgery report is obtained and the sperm and egg quality testing is complete, an appointment should be made with one of our Reproductive Endocrinology and Infertility subspecialty trained physicians.